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The United States is lagging behind the rest of the world on sodium reduction, despite strong demand from consumers and reduction initiatives developed by many major food companies.

From 2010 to 2015, the number of countries with sodium reduction policies in place more than doubled, reaching 75. So far, 12 have reported population-wide reductions in sodium intake. And while the Food and Drug Administration issued voluntary sodium reduction guidance in June 2016, the guidance is still in draft form. Public health advocates argue that the agency lacks the power to insist on more significant cuts.

“The problem is that it’s entirely voluntary,” Graham MacGregor, chairman of World Action on Salt and Health, told Food Dive. “The question is how far any of the companies are actually following any of the targets because there’s no real incentive.”

Cutbacks and new ingredients

Still, the FDA’s move has spurred the creation of sodium reduction ingredients. Cargill Salt has said it will open a new potassium chloride facility in Watkins Glen, New York later this year in response to food companies looking to cut sodium. Major players like Mars and Nestlé have also announced reduction initiatives in anticipation of the FDA’s guidelines.

It’s hard to quantify what kind of impact this trend will have. Few companies highlight reduced sodium on product packaging for fear of consumer backlash, as many people associate lower salt levels with weaker flavor. According to Mintel, the proportion of new food products that carry such claims has hovered around 3% for the past five years.

“The problem is that it’s entirely voluntary. The question is how far any of the companies are actually following any of the targets because there’s no real incentive.”

Graham MacGregor

Chairman, World Action on Salt and Health

One thing’s for certain — it’s a movement that’s necessary for the health of American consumers. According to the Centers for Disease Control and Prevention, 90% of children and 89% of adults consume more than the recommended sodium levels. The agency estimates that more than three-quarters of the sodium Americans’ consume comes from processed and restaurant foods. The CDC’s data does not, however, take into account salted added during cooking or at the table, meaning the actual salt intake for U.S. consumers could be even higher.

Average consumption is about 3,400 miligrams per day, according to the American Heart Association. Researchers have estimated that cutting this to 2,300 miligrams — the aim of the FDA’s 10-year targets — could prevent 500,000 premature deaths from stroke and heart attack in a decade, and save nearly $100 billion in health care costs.

“[Salt consumption is] killing hundreds of thousands of Americans and it’s entirely unnecessary,” MacGregor said. “The United States is likely to be the last country to fall into line with this and it should be leading the way.”

Challenges and reduction efforts

The Grocery Manufacturers Association has said that two years is not enough time to achieve the short-term reductions requested by the FDA, and has asked for at least four years — as well as changes to how food categories are defined in the draft guidance. GMA pointed out that many of its member companies had already made significant sodium cuts.

While the amount of sodium in U.S. packaged foods fell 12% from 2000 to 2014, according to a recent studypublished in the Journal of the American Medical Association. However, population-wide sodium consumption has hardly budged, despite 40 years of voluntary sodium reduction policies.

While sodium levels in packaged foods have fallen, “consumers were also shifting their eating patterns and consuming more foods away from home”, GMA said, suggesting that sodium reduction policies need to take into account changing consumer behaviors. With this in mind, the FDA’s voluntary guidelines target food companies and restaurants alike.

Jim O’Hara, Director of Health Promotion Policy at the Center for Science in the Public Interest, told Food Dive that the two-year targets were easily achievable for the food industry — especially considering that they were set on a 2010 baseline.

“It’s killing hundreds of thousands of Americans and it’s entirely unnecessary. The United States is likely to be the last country to fall into line with this and it should be leading the way.”

Graham MacGregor

Chairman of World Action on Salt and Health

Despite GMA’s concerns about the FDA targets, many of its members are taking the initiative to further pursue sodium reduction, and ingredients manufacturers continue to come up with innovative ways to approach the challenge.

“They are responding to consumer demand,” said O’Hara said of the companies. “A substantial majority of consumers know that there’s too much sodium in their food and they want less.”

A recent survey from the American Heart Association found that concern over sodium is growing. Sixty-four percent of consumers are now trying to keep their sodium consumption in check last year — up from 58% in 2013. And 62% said they wanted government to be involved in setting limits on sodium in packaged and restaurant foods, up from 56% in 2013.

“The GMA has dragged its feet even though many of its companies are doing sodium reduction,” O’Hara said. “And you have many members of Congress who are acting ideologically and against the consensus of science and putting up roadblocks even on the voluntary guidelines.”

One of those roadblocks is in the fiscal year 2017 Agriculture Appropriations Bill, which forbids the FDA from dealing with the 10-year targets. Instead, a committee is due to be set up later this year to update the sodium and potassium dietary reference intake (DRI) — the recommended amount of nutrients that healthy people should eat from the National Academy of Sciences' Institute of Medicine — which haven’t been updated since 2005. It should take the committee about 18 months to do its work, and only then could the FDA start looking at the 10-year targets within the context of the new guidelines.

“I don’t think that any of us who have been following the science expect that the DRIs will change that much,” O’Hara said, adding that companies will continue to cut sodium.

“You have many members of Congress who are acting ideologically and against the consensus of science and putting up roadblocks even on the voluntary guidelines.”

Jim O'Hara

Director of health promotion policy, Center for Science in the Public Interest

“The real question is whether the entire population is going to benefit, which is only going to happen if there is federal action to protect Americans across the board,” he said.

The CSPI has been pressuring the FDA and industry alike for decades on sodium reduction, and sees the agency’s publication of draft voluntary guidance as a response to its efforts.

“A few points on that: it was draft, it was voluntary, and it was guidance — but it was still a step forward,” O’Hara said.

International initiatives

Despite decades of research and debate about sodium’s role in heart disease and stroke, some eye-catching headlines have argued that its effect may be exaggerated. However, other countries’ sodium reduction policies provide some of the greatest support for cutting intakes.

In Finland, where a sodium reduction campaign began in the 1970s, average consumption fell by about a third in 30 years to about 2,800 mg a day for women and 3,320 mg a day for men. During the same time period,average blood pressurefell, and there was a 75% to 80% decrease in both stroke and coronary heart disease mortality. The U.K. has had a similar experience, and managed to cut sodium intakes even faster – by about 30% through 20 years. The World Health Organization has said that monitoring systems for sodium reduction and health impacts were crucial to the success of the programs in both countries.

Meanwhile, the toolbox of options available to food manufacturers to reduce sodium has become increasingly comprehensive — and it needs to be. Apart from contributing taste, salt plays otherimportant functional roles in food, such as extending shelf life, controlling yeast fermentation, affecting the color of baked goods and binding water in meat products. Potassium chloride is one of the most commonly used alternatives because it’s functionality is similar to that of sodium chloride, but it also has a metallic taste that may need to be masked with other ingredients.

“The real question is whether the entire population is going to benefit, which is only going to happen if there is federal action to protect Americans across the board.”

Jim O'Hara

Director of health promotion policy, Center for Science in the Public Interest

Scientists working in the sodium reduction field say the ingredients currently available to the food industry can cut sodium by 20% to 30% with no impact on taste. To achieve deeper cuts, more research is needed into salt taste receptors and how taste perception works. That said, companies and consumers alike may also overestimate desire for saltiness, and research has shown that cutting sodium without using replacement ingredients at all can also be an effective strategy.

Referring to manufacturers’ experience in the U.K., MacGregor said, “Some companies made quite substantial reductions quite quickly and others made them quite slowly. Nobody noticed. When you are eating a meal you don’t compare it side by side.”

However, O'Hara said, the United States has a long way to go.

“The bottom line is that the United States continues to lag behind other countries, the U.K. included, when it comes to any comprehensive sodium reduction policy," O'Hara said. The targets in and of themselves, if they were met, would go a long way to reducing sodium consumption among Americans.”